Four Prescription Policy

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Beginning April 1, 2013, the Illinois Department of Healthcare and Family Services will reduce the number of prescriptions that can be filled in a thirty-day period, without prior authorization, from five to four.

The purpose of the four prescription policy is to have providers review their patients' entire medication regimen and where possible and clinically appropriate, reduce duplication, unnecessary medications, polypharmacy, etc. The four prescription policy was developed as a result of budget negotiations, but best-practices call for an annual review of the full regimen of prescriptions for any patient. The four prescription policy is not a "hard" limit. Medicaid patients can and should have access to medications that are medically necessary, even if they exceed four prescriptions per 30 days. The policy simply requires prior approval for prescriptions above the limit, for the purpose set forth above.

Certain drugs do not require prior approval due to the Four Prescription Policy, and you should not request prior authorization for those drugs. The classes of drugs that do not require prior authorization are listed below:

Oncolytics

Anti-Retroviral Agents

Contraceptives

Immunosuppressives

Over-the-counter Drugs

Non-drug items such as blood glucose monitors and test strips

Currently, prescriptions for children under the age of 19 will not reject as a result of the policy. In addition, currently, prescriptions for clients residing in a Community Integrated Living Arrangement (CILA) or a Supportive Living Facility (SLF) will not reject as long as their residence in the CILA or SLF is properly recorded in the department's eligibility system. The department will continue to phase in the implementation based on capacity.

Requesting a Four Prescription Policy Override Prior Approval:

Emergency Situations:

During non-business hours such as evenings and weekends, when department staff are not available to make a determination on a four prescription policy override prior authorization request, the pharmacy can dispense, and the department will pay for, an emergency 72-hour supply of a covered prescription drug to an eligible client in an emergency situation. The pharmacy is responsible for following up with a prior approval request for the emergency supply.